Of proxies and POLSTs: The good and the bad in end-of-life planning

Fr. Tadeusz Pacholczyk

Planning for end-of-life situations is important. We should put in place an advance directive before our health takes a serious turn for the worse and we are no longer able to indicate our own wishes or make our own decisions. Advance directives can be of two types: living wills and health care agents.

The best approach is to choose a health care agent (a.k.a. a “proxy” or a “durable power of attorney for health care”). Our agent then makes decisions on our behalf when we become incapacitated. We should designate in writing who our health care proxy will be. The National Catholic Bioethics Center (www.ncbcenter.org) and many individual state Catholic conferences offer helpful forms that can be used to designate our proxy. Copies of our completed health care proxy designation forms should be shared with our proxy, our doctors, nurse practitioners, hospice personnel, family members and other relevant parties.

In addition to choosing a health care proxy, some individuals may also decide to write up a living will in which they state their wishes regarding end-of-life care. Living wills raise concerns, however, because these documents attempt to describe our wishes about various medical situations before those situations actually arise, and may end up limiting choices in unreasonable ways. Given the breathtaking pace of medical advances, a person’s decisions today about what care to receive or refuse may not make sense at a later timepoint. In the final analysis, it is impossible and unrealistic to try to cover every medical situation in a living will, and it is preferable to have a proxy, a person we trust, who can interact with the hospital and the health care team, weigh options in real time, and make appropriate decisions for us as we need it.

A new type of living will known as a “POLST” form — a tool for advance planning — also raises concerns. The POLST form (which stands for Physician Orders for Life Sustaining Treatment) is a document that establishes actionable medical orders for a patient’s healthcare. The form is typically filled out with the help of trained “facilitators” — usually not physicians — who ask questions about patients’ health care wishes, and check boxes on the form that correspond to their answers. The facilitators receive training that can lead them to paint a rather biased picture of treatment options for patients, emphasizing potential negative side effects while side-stepping potential benefits or positive outcomes.

POLST forms thus raise several significant moral concerns:

1. The approach encouraged by the use of POLST forms may end up skewed toward options of non-treatment and may encourage premature withdrawal of treatments from patients who can still benefit from them.

2. Filling out a POLST form may preclude a proxy from exercising his or her power to protect the rights of the patient, since the form sets in motion actual medical orders that a medical professional must follow. As a set of standing medical orders, the POLST approach is inflexible. Many POLST forms begin with language like this: “First follow these orders, then contact physician or health care provider.” Straightforwardly following orders created outside of a particular situation may be ill-advised, improper and even harmful to the patient.

3. In some states, the signature of the patient (or his or her proxy) is not required on the POLST. After the form has been filled out, it is typically forwarded to a physician (or in some states to a nurse practitioner or a physician’s assistant) who is expected to sign the form. Thus, in some states, a POLST form could conceivably be placed into a patient’s medical record without the patient’s knowledge or informed consent. In a recent article about POLST forms in the Journal of Palliative Medicine, approximately 95 percent of the POLST forms sampled from Wisconsin were not signed by patients or by their surrogates. Fortunately, in some other states like Louisiana, the patient’s signature or the signature of the proxy is mandatory for the form to go into effect.

The implementation of a POLST form can thus be used to manipulate patients when they are sick and vulnerable, and can even lead to mandated orders for non-treatment in a way that constitutes euthanasia. The POLST template represents a fundamentally flawed approach to end-of-life planning, relying at its core on potentially inappropriate medical orders and dubious approaches to obtaining patient consent.

Notwithstanding the pressure that may be brought to bear on a patient, no one is required to agree to the implementation of a POLST form. Patients are free to decline to answer POLST questions from a facilitator, and should not hesitate to let it be known that they instead plan to rely on their proxy for end-of-life decision making, and intend to discuss their healthcare options uniquely with their attending physician.

 

COMING UP: Celebrate and support the sacred gift of life

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Editor’s Note: This column is adapted from Archbishop Aquila’s remarks to the 2018 Celebrate Life March, which took place on January 13th in front of the Colorado State Capitol building.

As we gather today to celebrate life, we must remember three things: 1) life is a gift, 2) life is sacred, and 3) rebuilding a culture of life requires joy.

We are here today to celebrate our joy over the gift of life. Every minute and every day we live presents us with an abundance of gifts that seem mundane and are often overlooked: our health, the gift of creation, or something as simple as having food on our plates. Above all, we should give thanks for the gift of life!

As people involved in protecting life at every stage, the challenge we face is not just one of providing resources to mothers and fathers in need or ensuring people battling a terminal illness have good palliative care. Our challenge is to also communicate to them that they are loved, that their unborn child or their own lives are gifts, no matter the circumstances.

Many of us fought in 2016 to prevent doctor-assisted suicide from becoming legal in Colorado, and one person who helped in that effort was a courageous man named J.J. Hanson. J.J. was a Marine veteran and father of two young children who was working for a real estate investment firm in Florida when he found out he had glioblastoma multiforme brain cancer. His doctors told him that it was a very aggressive cancer that meant he only had four months to live.

Despite his odds, J.J. resolved to fight. His motto was: “Every single day is a gift, and we can’t let that go.” What’s even more remarkable is the fact that J.J. dedicated his time and energy to fighting the legalization of assisted suicide around the country, all while undergoing chemotherapy and other treatments. There was hardly a speaking engagement or trip to testify before a legislature that J.J. turned down. His conviction that life was a gift propelled him to defend that gift however he could. As pro-life people, we need to have that same conviction.

Just about two weeks ago, on December 30th, J.J. was called home to the Father – three years beyond what doctors told him to expect. St. Anthony of Padua church in upstate New York, where his funeral was held, was filled with people who paid tribute to how J.J. inspired them to embrace every moment of life, no matter its difficulties as a gift, not something to be thrown away.

All of us are called to embrace life as J.J. did, and in doing so we will help recover the culture of life that is being neglected or forgotten as people cast God and truth aside.

I have said that life is a gift, and while that is true, it’s more than that. Life is also sacred. Life is sacred because it comes from God, the God who is love and who has loved us first. Our lives are also sacred because our beings are made in God’s image and likeness.

We are called to participate in the love of God and to see that every human being, from the moment of conception until natural death, is invited into relationship with God. We are called to ensure that life is set aside for God, that it is honored and recognized as sacred.

The struggle for so many today is that they do not even believe in a god; their only god is themselves. They truly do not believe in the God who is love. And because of this limited worldview, a person’s life can lose its value if their “quality of life” declines.

In the words of Pope Francis to participants in the 2013 Day for Life, “All life has inestimable value even the weakest and most vulnerable, the sick, the old, the unborn and the poor, are masterpieces of God’s creation, made in his own image, destined to live forever, and deserving of the utmost reverence and respect.”

When Jesus speaks about the Judgement of the Nations in Matthew 25, he tells us that life is always sacred by saying that when we love the weak and vulnerable, we are loving him.

The more that we can love the sacred gift of life and celebrate it with joy, the more we will contribute to building a true culture of life in the U.S.

A wonderful example of concretely loving the sacred gift of life is a story I recently heard about a 15-year-old Colorado teenager named Missy, who showed up with her parents at an abortion clinic in Albuquerque, New Mexico.

Missy was a sophomore in high school and was in her second trimester of pregnancy. As they approached the clinic, some pro-life volunteers who were parked nearby in a mobile crisis pregnancy van saw them and invited them inside. The volunteers learned that Missy wanted to complete high school and that this desire was pushing her to consider an abortion. One of the volunteers told Missy about how she was faced with the same choice as a teen and chose to keep her child. “It wasn’t easy, but it was amazing,” she reassured Missy.

Missy also worried about the father of the child not being around, to which her dad responded by taking her hand and saying, “I’ll be that man in your child’s life.”

This kind of accompaniment and willingness to heroically support the gift of life is vitally important to forming a culture that welcomes the unborn, the elderly, the disabled and the dying as a gift.

Building a culture of life begins by first receiving the love of the Father, who loves each of us as his sons and daughters. He never abandons us, even though we might abandon him or reject his love.

A culture of life grows when we share his love with others, helping them to embrace life as a gift and a joy, rather than a burden.

Life is a gift, it is sacred and our celebration of the joy of life helps build a culture of life.

I encourage you to be those who are unafraid to give witness to life. Be not afraid to give witness to life. Even though people might ridicule you, yell at you, or reject you, know that Jesus experienced it all so that you might have life, and life abundantly.

May God bless you and help you celebrate life in 2018!